#219 Diabetes Pro Tip: Insulin Pumping

Scott and Jenny Smith, CDE share insights on type 1 diabetes care.….

I am thrilled to welcome Jenny Smith, CDE back to the show. Jenny will be joining us for an extended series of conversations that focus solely on the management ideas that we discuss on the podcast.

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Alexa - Google Play/Android - iHeart Radio -  Radio Public or their favorite podcast app.

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:00
Hello, everyone, and welcome to the sixth installment of my diabetes pro tip series with CDE Jenny Smith. Today, Jenny and I will be talking about insulin pumping. But if you're not using a pump still listen, lots of good information. As a matter of fact, listen in order, you want to start at the beginning and work your way through this series is designed to tell a story. This series is a narrative about how I manage my daughter's type one diabetes. The ideas you're hearing in these episodes, coupled with my favorite technology, is how we've kept my daughter's a one c between five two and six two with absolutely no diet restrictions for over five years. And while we're talking about that, this episode of The Juicebox Podcast is sponsored by Omni pod Dexcom dancing for diabetes, and real good foods. To get a free no obligation pod experience kit from Omni pod go to my omnipod.com forward slash juice box. Want to check out the Dexcom g six dexcom.com forward slash juice box. Go to real good foods that calm and when you place your order, use the offer code juice box and save 20% on your entire order. And never forget to go to dancing for diabetes.com just to see good people doing good things for people living with type one that's dancing the number four diabetes.com

Welcome back to the diabetes pro tip series with CDE Jenny Smith, I'm glad you're here. In this episode, Jenny and I talk all about insulin pumping and the ideas that surround the practice. Please don't forget that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And always consult a physician before becoming bold with insulin or making any changes to your medical plan. And double Don't forget that if you're interested in hiring Jenny privately, you can do that at integrated diabetes comm You can find links for Jenny at Juicebox podcast.com, or in the show notes of your podcast app.

We are back talking about insulin pumps today. Awesome. And the idea of pumping in general not any specific pump, although we might go over the ones that are available at the moment. So we discussed in the MDI episode that it's tough to get an insulin pump right away, you'd have to be have great insurance, you'd have to be able to get over the What do we want to call them roadblocks that some endo offices put up to you getting? Right getting an insulin pump. But but congratulations, if you've gotten that far, and you're thinking about getting an insulin pump. Why do you think? Well, do you think Let me ask you, do you think pumping has advantages over MDI? And if so, what are they?

Jennifer Smith, CDE 2:55
Yeah, I mean, a broad a broad statement. Yes, there are advantages. I think there are pros and cons to everything. But there are a lot of pros. I think one of the biggest ones is precision in dosing. I mean, you know, from the standpoint of injections, we can dose accurately, I quote accurately, to the half a unit with an injection, right? I mean, I've even got a couple of friends who still do MDI don't like pumping and, and they've sort of figured out how to get that quarter unit in an injection. But is that accurate? No, it's not like the pumps accuracy, you know, pumps can pumpkin, pumpkin get down to the point 05 or the point 025 of a unit. That's, that's precise. That's minuscule, you know, and for the broad spectrum of people that need insulin in different doses, the very, very little to the adult who is very, very sensitive for whatever reason, that can be important. So,

Scott Benner 4:07
okay, and I agree, I think that when, especially when they're younger, I've used mo I've had moments with Arden where it's a point one or a point to Bolus that can really move somebody and the, you know, the obviously, the lower your body weight, the more that kind of precision makes incredible differences. I guess the con to that can be if you are so small, it's possible that it might be difficult to set your basal rates up because if your basal needs are that little in the beginning, you can do that. I've seen people do all kinds of crazy stuff like set a basal rate on for one hour off for the neck, back and forth. And that's that there's a way to get through that. I think if you have a smaller child and you want to pump, there's a way to accomplish it. There is

Jennifer Smith, CDE 4:55
absolutely so precision definitely and then you know i The icebergs that kind of pop up in your day. And you know, you I know your strategy and a lot of people strategy is kind of the navigation of blood sugar, right? And utilizing the smart tools on an insulin pump smart being things like the extended bolus and the temporary bazel feature. You cannot do that with an injection. You just can't. And that is that's another huge pro to a pump.

Scott Benner 5:29
Yeah, I, I can't say I agree anymore. I'm in full agreement. I didn't understand it all about pumping. When Arden was injecting, right? There were just a lot of words I didn't understand people would talk about bolusing and all that. What's that carb ratio? I have no idea. I know a little bit for me, Jackie. But it was so much more specific talking about pumping. I had its own language. And I've mentioned before that as we were in Arden's pump class at at her children's hospital. And I recognized that insulin was going to be used, like fast acting insulin was going to be used as basal insulin. Yep. And that I could turn it off and turn it back on and increase it and decrease it. I'm telling you angels,

Jennifer Smith, CDE 6:11
like a light bulb light bulbs are going off,

Scott Benner 6:13
like everything happened. I was like, okay, immediately. Yes, please. I genuinely think that before you have a pump, and for a lot of people after you have it, people just believe the pump is a way to avoid injecting. And I want to I want to, as we do the overview about in some pumping today, I want to show them that it's just so much more than that. So it is

Jennifer Smith, CDE 6:36
absolutely and I think another piece to definitely clear up. Even for anybody who might be listening to these that doesn't necessarily interact or is a caregiver for somebody that with diabetes, but they've come across it because they just want information. A pump is not the magic, do it all. You don't plug it in, and it takes care of everything that is is not the case. And for those who might be dying, newly diagnosed in our hearing Oh pump is like the magic thing. It does all these ones. It does what you tell it to do. And it does it based on the parameters you set within the pump. There's it's it's personal input is what makes the pump as beneficial as it can be. So you can then see that if you don't know what you're doing.

It could be not that's the best thing.

Scott Benner 7:31
Sometimes you hear people say I've had this pump for a month. And I'm thinking of going back because I think they had doing what I need. Yeah. And I think they had that expectation like look, I bought the pump I put it on Why did my UNC not go down? How come my spikes aren't going away? Why is my body and in some cases, people's blood sugars get worse in the in the in the beginning because they don't get their bazel setup correctly, right. Or, or I think for some people, your insulin needs change, sometimes greater or lesser, when you go from injecting the pumping

Jennifer Smith, CDE 8:03
because of the precision, especially of that bazel, sometimes with the imprecision of an injected basal insulin, and the fact that it isn't based on your physiologic need and the change through the course of the day, that basal insulin could be off via injection at a time when you need less insulin. And so things look like they're happening around a bolus when it really isn't the bolus is problem. It's the bazel. So getting that bazel set is huge. It's like the foundation of a house and the opposite as well to not instead of the boluses problem. You can't You can't give the Bolus credit. Sometimes Sometimes you have a lower stable blood sugar that you think you made this great Bolus off Oh,

Scott Benner 8:48
but but your 11 year or your lantis, you have too much of it, or it's just it's working stronger at that point or something like that. So when you switch to a pump, and you go to these more precise basal rates, using a fast acting insulin in the background, then if you don't have that correct at that number, you don't you no longer have that sort of like I don't know what to call it like when you inject basal insulin, it's just sort of a Is it a catch all? Is it a is it it's a blanket of insulin that you made?

Jennifer Smith, CDE 9:18
Yeah, that's a good way to think about it. It's kind of a blanket of insulin, but it's not a blanket that's always warm and cozy at the right places through the course of the day. I mean, I can my example is before I started pumping, I was using Lantus was my basal insulin, and I took it in the evening. If I did not have a snack, when I went to bed after taking it, I could have bet a million dollars that I didn't have that I would have a low blood sugar between two and 3am. And that's because

Scott Benner 9:49
your new basal insulin starts coming online and it works.

Jennifer Smith, CDE 9:52
And it worked the way that it did. I needed less insulin at that time, but lantis didn't know that Atlantis was like, Hey, you put me in here. I'm gonna get a tour of this, I'm going to do my thing that I was supposed to be doing right. So I needed at that dose for the rest of the day. But I didn't need that dose for that action time of the morning.

Scott Benner 10:11
So that's our first kind of lesson here with pumping, when you get an insulin pump, your basal rates need to be dialed in. And there's two things about that. The first thing is, and this, of course, is not true for everybody. But I do meet a lot of people whose doctors under welcome them with basal insulin, when they put them on a pump I because they don't want to cause a low, they don't necessarily tell you that going out of the office or you don't expect it. And so you get hot, you get home, you're high all the time. And it doesn't ever occur to people that it's bazel. So I get on a pump, get the bazel. Right, I think the next thing is

Jennifer Smith, CDE 10:48
one one comment about that as adjustment factor. And you mentioned it before insulin use may change going on a pump, we usually find give or take, we usually find that when you start on a pump, your bazel injected insulin dose in the pump will need to be about 10, sometimes 20% less than what you were injecting in your basal dose. So let's say your basal insulin is giving you 20 units a day via Lantus or levemir, to you know, to jail or whatever it might be 10% less than that is two units less. So we would actually dose your bazel in the pump on 18 units across that 24 hours versus 20 units. Because it's it seems to be that the body responds better to that one type of insulin or rapid and coming in at one precise point in the body all the time. Rather than being injected like all over

Scott Benner 11:49
really be either then you can you can get your pump set up with baselines and find yourself high all the time and realize your basis not enough or, or too low or where you have to come in. So that is why doctors start that way. Because I guess more over the likelihood is you'll need less. But for the people who that's not true for it's the situation I described. Right? So what we're really saying is, you're not going to know until you know, but but figure it out, get it in there and figure it out. I also want to know what you think about multiple bazel rates in the beginning, because in my mind, I think you set one up, and then you start adjusting off of that one.

Jennifer Smith, CDE 12:26
Right? Agreed? Absolutely. Even when I started pumping, you know, as an adult once there were finally pumps, like Omni pod. And that wasn't about tubing. I wanted that pod. But when I started doing that, you know, I actually did I started on one solid basal rate. And I was already an educator. So I knew about pumps, I just, you know. But yeah, you have to test you have to evaluate and see what does that one solid diesel? Where do I need it to be less? Where do I need it to be more for how long?

Scott Benner 13:02
Yep. And we're going to talk about the adjustments in our own little piece of this. So okay, so let's move on now to to the idea of bolusing. So I want everyone to understand that the doctor, your doctor is going your pump trainer, whoever you talk to is going to do their best based off of what they know about you to set up an insulin to carb ratio in the pump. But it is incredibly important to know that that is a number that is not completely made up. But it is a guess on some level. And so if you're putting insulin in for a bolus, and you just you say to yourself, man, I counted these carbs 100% correctly. And it's telling me three units. But I used to eat this food on injections, and I had to inject four units or two units or it was different in some way. I just think it's incredibly important to remember that your doctor just did the best they could putting that in there. And this becomes where sort of the next step of how people get confused starting pumping. Because things don't go the way they expect. And they never diagnose the idea that it's the it's the insulin and I mean, this series is obviously it's all about timing and amount, right, you're using the right amount at the right time. Their minds. I think Siri just heard me say something. Sorry. Sorry. It wasn't. It says, Hey, Siri, I have it's obviously it's all about timing. Shut up Siri. Sorry. My point is, is that you're our brains somehow focus on the idea of the pump specifically and not and we forget about the insulin. So I got on a pump and something didn't go the way I wanted. There's something wrong with the pump, that the leap you make. It's the it's it's very likely the insulin, so you can't jump over the obvious answers to get to the other ones. Then Then We run into the problem that people don't want to make insulin adjustments in their pumps in the beginning. So for all of you listening who are about to start pumping or a noodle pumping, and you're seeing something in your heart, you know, isn't right. I would implore you not to sit around for three months waiting for your next endo appointment. Right? Okay. So if you're not, if your blood sugar's high, you probably have not enough insulin, it's possible that you know, you haven't timed it, right? But there's safe ways to make small adjustments to your insulin on your own. Right. And absolutely. And so, would you talk to me about how you would How would you if someone called you and said, Hey, I don't know what to do. And you you looked at their graph and said, I think your basal insulin needs to be turned up or turned down? What percentage do you tell them to to move at? Like a kid in a candy shop, I just spent an hour using the Omni pod dash PDM. You may be listening to this now thinking it's not out yet, but but it will be very soon. And if it's already out, well, then, you know, welcome to time travel. While I was in that room, I got to use the new dash touchscreen, all color Bluetooth really fantastic. I also got to see the display and view apps that on the pod will be unveiling, Sophia, the caregiver of someone using it on the pod when they bolus you'll be able to see it on your app. You'll also be able to receive alerts on your app as a caregiver. And I know you're excited about that, there has never been a better time to use the tubeless insulin pump that Arden has been using for 11 years. The Omni pod. The best part, of course, is that Omni pod will offer you a free pod experience kit, they're going to send you a free demo of the pod. There's no obligation, it doesn't cost you anything, it comes right to your house, and you get to wear the pod to see if you like it. You don't have to just trust the guy on the podcast, you can see for yourself. So if you're switching to a pump or switching from a pump, in my opinion, there is no better choice than the Omni pod. You want to find out if I'm telling the truth. Go to my Omni pod.com Ford slash juice box and get yourself a pod experience get there's absolutely no obligation. It's 100% free. And if you can't remember that link, it's also available at Juicebox podcast.com. Or right there in the show notes of your podcast player. My Omni pod comm forward slash juicebox insulin pumping is absolutely terrific. And insulin pumping tubeless Lee with Omni pod is whatever terrific times a million is what percentage do you tell them to to move at

Jennifer Smith, CDE 17:44
it depends on what the overall picture looks like, you know, if there are small, if there are small, less aggressive looking changes to their blood sugars, but it's in a bazel only time period. And you can tell that obviously something is wrong, we recommend making adjustments if there's more than a 25 to 30 point shift up or down from a set blood sugar. So let's say if you're testing the overnight, you go to bed at this rock solid, you know one or two blood sugar, but by you know and that's 9pm. But by 1am, your blood sugar's at 201. That shouldn't happen on basal insulin, that's there's something incorrect there. So you know, with a shift like that, we would bump bazel probably by like a point one in that time period to offset the incoming flux of incoming need for extra insulin. Usually, if it's a smaller incremental change to blood sugar, you know, you're going from a blood sugar of 102 to 152, you probably don't need that much of a change. And so maybe more of like the point 05 in a rate, smaller increments to the point zero to five, which most of the pumps on the market can do. Not all of them, but some of them. So that may be something that you play with, especially if you feel like you're pretty sensitive to small changes in dosing, then you may want to start smaller and make an adjustment up or down. Right.

Scott Benner 19:14
And so again, it's a good place to point out that the numbers not important because we can't tell from one person to another. And I'll give you an amazing anecdote about that I was with a group of people this past weekend, there was a college age kid there who in my best guess was 610 and must have weighed 230 pounds. And his bazel rate was lower than my daughter's who is five, six and weighs 125 pounds. My daughter is also growing and you know gets a period and things like that. So you can't, you can't reach out into the public into back to your doctor and say Just tell me how much to turn it off. You know, like you have to pick an increment. That's not that's not crazy. It's not dangerous. Obviously. You're not Going to take 8.5 bazel and make it a one, you know, try point six. You know, like if you're if you're a little high trade point six, and then if you do it for a few hours and nothing's going on. I mean, try point seven like and you know, you might get to a point where you Oh, now I'm a little too low. And then again, I'll dial it back point six, five and, and make that decision on your own like, think it

Jennifer Smith, CDE 20:25
and certainly communicate with your provider. If you want some assistance thing, hey, you know, even calling your endo office, most often you get connected with a nurse, the nurse is then going to relay your message to the endo, you might get a call back, hopefully 24 hours, maybe 48, or, you know, whatever it might be, but at least you're acknowledging, hey, I'm seeing this issue. I'm making my adjustments because I'm the one living with diabetes 24 seven, I'm just telling you, so that if you've got any additional feedback,

Scott Benner 20:53
great to hear, yeah. But you can't, you definitely can't do what happens to some people, you just freeze because I want you to really consider what we've been talking about what you've been listening to going back to your doctor four times a year, and saying, hey, look at 90 days worth of my blood sugar's and adjust this and make it correct. It's just they're not guessing. But they're just doing their best and their best is limited because they're not with you. And so I know you're that it's probably happened to you before you sit and you stare at these blood sugars. And you think, well, this isn't what I was told. But just remember, you're getting this machine, and it needs to be dialed in. You just have to get it right, you got to get it running, right so that you can start enjoying the benefits which are significant. Once you get it going. And I will say that I was one of those people who got a pump for my daughter when she was four years old. Oh my god, over 10 years ago, wow. Yeah. And I slapped it on her. And then I stepped back and I looked at her blood sugar. And I looked at her. And I'm like, okay, just start going down. You know? Everybody get back this, this this, my gosh, back then this 8.9 a one see it's gonna be magically lower. Well, it did go down a little bit. but not a lot. I only went down a little bit because I guess I was able to bumper insulin a little more. That's where we started, right? Well, I guess a little more because back then if you missed on a bolus, doing it again met injecting again. And no one never wanted to do that. So you just waited and hoped and cross your fingers, right. But now I could give a little more in a little more. But in honesty, just adding an insulin pump without understanding it did not bring Arden's a one seat down that,

Jennifer Smith, CDE 22:36
that. I think it's kind of like, I mean, the adjustment is kind of like getting wheels aligned on a car, right? I mean, if you have, if you want to ride this straight line, you have to do these incremental adjustments so that you're not consistently like veering off there.

Scott Benner 22:54
Gotta rotate your tires, again, to get your your ball bearings all straightened down everything that was just the extent of my knowledge of cars, as we've heard, but you want you know, their engine, I joke a little bit I understand. So people who really understand cars, there's toe and camber, there's these these tiny adjustments that get made to your front wheels that keep your car moving straight. And it's the same situation. Those again, just like bumping and nudging blood sugars, these are tiny adjustments to get you where you want to be. And the difference between being 190 all day long. And 90 all day long, could just be point one, a half a unit of a change, depending on your size and your weight, your needs. The tiniest amount. And just imagine that, you know, we talked about all the time if you if you don't have enough basal insulin going when you Bolus, a lot of your Bolus is just replacing the Basal you don't

Jennifer Smith, CDE 23:48
have. And so that when the Bolus isn't there,

Scott Benner 23:51
you're wondering, Well, why I didn't even eat at this point today. And what's happening here, right? Why is this happening now? And so so you need to get these things straightened out. Now, I guess moving on to the idea of bolusing Yeah, before when you had your shots, you were counting your carbs, doing your thing, stick it in your pan or your needle and pushing it in there and just hoping you know, hoping for the best right? You are now opening yourself up to an entire world of Pre-Bolus saying and and doing it with

Unknown Speaker 24:22
different and what Pre-Bolus

Scott Benner 24:25
boluses all the things you're pumped, you know, well, first of all Pre-Bolus things not a setting. It's just the idea of putting in your insulin and giving it a headstart over the food that you're about to eat right. But an extended bolus. So we're talking right now it's 11am. And 40 minutes ago, Arden texted me and said lunch is soonish. I want you to really hear that. She didn't say she didn't say in 10 minutes. He didn't say 20 minutes from now she said soonish and I know based off of how this year is going at school, we're going to Pre-Bolus here And I thought about what was in her meal. There's not anything incredibly like simple sugary, that's gonna spike her right away. And she was 106 when we did this. So she'd been a little resistant towards the end of her period this week. We did a Temp Basal increase a 40% for an hour and a half. And so that takes Arden's bazel rate from 1.4 to whatever 40% more of that is for an hour and a half. And then I did a 11 and a half unit Bolus. We did 20% of it up front and the balance over an hour. So 20, whatever 20% of 11 and a half in 11 and a half units is goes in when she pushes the button. The balance of that goes in incrementally over the next 60 minutes coming online and getting active along the way. And now it's 40 minutes later and Arden's blood sugar is stable and 90. And she probably started eating 20 minutes ago or so. Mm hmm. I'm expecting the food to begin to impact her right now. Yeah, right. And so we got we got momentum on our side for the insulin, we've got our going down. You know, we've got that tug of war set up we've we've given you know, we were letting the insulin cheat. And we're going well, now, I'll tell you right now, if 20 minutes from now she starts curling back up. I might you know, if there's any temp, if there's any extended bolus left, I might cancel it and put it all in at once a extended bolus is over, I'm going to go through I might have missed a little bit. There's all kinds of different adjustments you can make to change the timing and the amount of the insulin. I want you though to talk about first about extended boluses. And I want you to talk about the way I know I can't, which is technically and smartly. Yeah.

Jennifer Smith, CDE 26:52
I think you give very good description, I think the biggest thing to understand to begin with when with an extended bolus is that all pumps can do them. They all term them or call them something a little bit different. And it really just kind of boils down to how you're telling the pump to give this this dose for a meal. Whether you want it all up front, meaning like you'd give an injection, you get this whole normal amount of insulin deposited under the skin all at one time. That's normal. And extended allows your pump to drip drip, drip drip, almost like your bazel is dripping all day. But in a time period you've defined whether it's 30 minutes, an hour, three hours, you told the pump, I want to deliver 11 units over the course of some now and some in an hour time period. That's what we kind of refer to as a dual wave bolus to dual being you get some normal up front, meaning a bump right now like an injection. And then the rest of the the meal like you said 2080, right 20% now is the normal 80% over an hour. So your pump is now saying Okay, I'm going to drip drip drip drip drip this 80% in and by the end of an hour, that whole extra 80% will have been dripped in. But it's action time then is pushed out because you didn't deliver it all right now that last pulse of insulin at end of our one still has now an active insulin time for whatever you have set in your pump, three hours, four hours, five hours out from that last active pulse. So I think that's the important thing to know about extended boluses some people first start to think of them as Okay, well, I'm going to get some insulin, but then three hours from now it's going to give me the rest of my insulin. That's not how extended work. They always give some and extend some drip drip. Or you might want to say for this meal, I'm eating a big ol plate of broccoli and a chicken breast. There's carb in that broccoli that you do have to count and cover. Is that broccoli gonna hit you like white rice. No way. It certainly isn't. So a meal like that. You may say okay with these really low glycemic carbs. I'm going to extend the full bowl is something we call a square bolus. You take that meal that's suggested as a bolus, and you drip drip drip the whole amount of it out over your designated time period. And there are different reasons for all of those. Yes,

Scott Benner 29:33
and you got to figure them out. And you can I was with a person eating low carb this past weekend. And we sat down at a restaurant. She had a meal that you would expect had almost no carbs in it but a ton of protein. She said she ate she sat and ate it. We got in the car drove away it's now 20 minutes or more past when the food was and she grabbed her PDM from around the clock. give herself insulin, because she does know she needs insulin for that protein. And but she didn't need it. If she would have bolus and sat down or Pre-Bolus sat down, she would have gotten incredibly low. Yeah. And she, it was amazing to see somebody figure that out. I was, I'm going to add what I learned about that, to me, like how the protein needs more later.

Jennifer Smith, CDE 30:19
Absolutely. It takes into the immune takes into the fact that we know these things from a set of rules. But I mean, the classic your diabetes may vary. Your diabetes bolusing strategy will vary. Well, it really yeah. Not Not me, it will vary. I mean, I my breakfast every morning, I've got a friend who eats the same exact breakfast after talking to me, she was like, Wow, that sounds awesome. I like it. I want to give it a try. Blah, blah, blah. And so now she loves it. Her bowl of strategy for it is similar, but not 100% of what I do. It's different because physiologically, she's different. Yeah.

Scott Benner 31:01
And and so if you've ever heard me speak live somewhere, there'll be a moment where someone in the audience asks the, you know, the question, how much how long, you know, and I go, I don't know, figure it out.

Jennifer Smith, CDE 31:13
Starting places, there are some starting sure things. It's like kind of like, you know, the How much do you adjust the bays? A lot? Oh, point point. Oh, 5.1. It's a starting place, right? Sure. Give it a try. If it doesn't work, Okay, next time you adjust different, right,

Scott Benner 31:30
and I'm more aggressive, like when I adjust basal rates, I adjust them like 30% of the time, because I'd rather cause a low and then back down from the low to find a level spot than to

Jennifer Smith, CDE 31:40
go high for several days

Scott Benner 31:43
in the high, right. Because also because I feel like you're getting a more accurate depiction of what's happening. If you're using more insulin, when you're using less insulin, then there could be resistance going on. And maybe

Jennifer Smith, CDE 31:54
you know me and the feel to them that you have to correct and so you never really get a true picture of what does the basal adjustment really just do because now I'm high and I want to correct and I'm not going to leave it high. So I don't understand what the bazel I know, I just know it's not enough,

Scott Benner 32:08
you'll get a look into my parenting style that way too. Whenever my children asked me something, I respond immediately with no. And then we work backwards from now. And so I sort of do the same thing on the inside, I slam the insulin, and then I work backwards from there to find a level spot. I wanted to say about insulin action time, it's another idea of settings near pump, right? So there's an amount of time that they you know, insulin should work in your body, like how long from when you put it into when it stops working. And you'll see people say all different kinds of numbers, you know, for hours, you know, it's different for me here and there. Same insulin, you know, they're using one kind of insulin. Some personal say, Well, my action time is four hours, my x times three hours. Arden uses a pager and her insulin action time and her pump is set at two hours. And so I have found that when you Bolus art and that Bolus stops having any effect on her in by two hours. Wow. Most of the time. Some of the time now. I don't know how to tell you the difference, but most of the time it's Yes. Last night it was now last night I couldn't get Arden's blood sugar to budge off of one ad. It didn't matter what I did. She had incredibly Carbo rific afternoon. Like I said, she still has her period. And you know she's going along. Now there's a moment where I'm like pushing and pushing and pushing and I'm finally that guy. This is enough like this insulin is going to start working eventually. And it did later at night after a hot shower. Her blood sugar started coming down and we had to catch it. It was hours and hours later. That doesn't make Arden's insulin action time six hours, right, right. That's a specific situation. Most times insulin I put in now doesn't cause her to get low Two hours later. Now keep in mind, insulin on board is calculated by the insulin action time set up in your pocket. Am I right about that? Correct. Can you explain that for us, please?

Jennifer Smith, CDE 34:07
Yes. So insulin on board specifically uses your active insulin time that you have set in your pump. So for Arden, two hours if she were to get a bolus now for you know, at at 11:07am. Two hours from now, at 1:07pm. The pump would no longer identify active insulin on board from this Bolus, which means that if she chose to Bolus at 115 it's only going to factor in blood sugar and the carbs she tells it she's eating to give a bolus suggestion. However, within active insulin time, let's see, you know, an hour from now somebody's birthday comes up and they bring a big old big old tree to school and she's like, Hey, Dad, I'm totally

Scott Benner 34:58
I'm gonna need another 30 carbs over On top of what we just bought for an hour, right,

Jennifer Smith, CDE 35:02
exactly, but that was an hour ago. So your pump still assumes, hey, there's still insulin on board from this bolus that she gave an hour ago, there's this much active insulin left. Important thing about iob is that you have to feed the pump information in order for it to consider iob information being blood sugar, and carbs. If carbs are a piece in the picture here, right? Because if you do not feed the pump, a blood sugar, it doesn't know the effect of the insulin onboard that's still left. And to calculate the next bolus correctly, it sees the insulin on board, but it may not be able to adjust because it doesn't have a pinpoint of glucose value to now say, okay, she was an hour ago at 82. Now she's at 179. That insulin on board that's left is coming into the picture, but the pump also sees a higher blood sugar. So it's gonna say, okay, she's high. She wants to eat this much more. This is how I'm going to calculate the bolus despite there being active insulin left but

Scott Benner 36:16
in a situation where like, for instance, now Arden's blood sugar's 111. Okay. And I'm seeing a curve up on her CGM. But her pump right now if you test it right now say she didn't have a CGM she tested right now for that, you know, surprise treat an hour later. And, and it says, Oh, your blood sugar's 111. You have all this insulin on board from the meal, go ahead and eat that you don't need insulin for this you don't need, you don't need as much insulin for that. That would be stalking. Okay, and that's a word that doctors are going to throw at you. And they're going to mean for it to scare you. And, and maybe maybe it should, in the beginning, I'm not 100% sure, but what they're going to tell you is you can't stack insulin, because eventually it's going to, it's going to catch up to you. And it's going to make you low. I say to that, yes. If you don't need the insulin, if you do need the insulin, it's not stalking, it's rolling, knowing the difference is the is the trick, I guess. To go back to, I'm going to layman's terms a little bit more about insulin on board and action time if I can. So if you decide that your insulin action time is three hours, and by you, I mean, the doctor sits down says this is what it is for most of my kids this age, so I'm going to set it for three hours for you. But your insulin action time is actually less or more, then your pump is going to make decisions based off of that number. It doesn't make it right, I want to be clear at the pump doesn't have a magic sensor that's in you somewhere that knows that it's telling you the right thing it's making, it's making a static decision from a static number. That's not necessarily correct, it's probably a good guess. It probably won't hurt, you know, it's gonna err you on the side of caution a lot. It's going to keep you from being you know, from getting well.

Jennifer Smith, CDE 38:07
And I think that's a good it's a it's a very good point to bring up. Because what we've actually found, especially in the community of people who are doing the Do It Yourself looping types of pumps, which is a whole nother broad topic, but I bring it up in this mainly because what we've found is that the action time of rapid acting insulin is actually beyond what most people have it set in that their insulin pump. And the reason that we have it set for less time in an insulin pump, is because we inherently do not want to run high blood sugars. And so if we give the pump and active insulin time of three hours, when really that bolus is probably lasting about four hours for us. What it means is that at three hours and one minute after this bolus was delivered, if your blood sugar is still high, your pump now no longer sees any active insulin and it can bolus you more aggressively for the blood sugar that you now want to drive down. Right. Whereas if you had it set for four hours, at three hours in one minute, you were like I'm high I want a bolus to get this blood sugar down. Your pumps gonna be like, let's be a little conservative here because you still have this like quarter of that last bolus still working.

Scott Benner 39:31
We are now six episodes deep into the diabetes pro tip series. We're halfway through talking about insulin pumping. And next month, the episode about how to use a CGM like a ninja is going to come out. It's time guys. Let me be bold and say I think if you don't have a dexcom at this point, if you want one, you have to take the leap. You have to go to dexcom.com forward slash juice box and get started right now. But if you need to be reminded again, why I'm happy to do that for you. Good Dexcom g six continuous glucose monitor is not only going to show you what your blood sugar is, it's not only going to keep you from having to check with a meter, it is going to show you the direction and speed that your blood sugar is moving. how fast you falling? How fast are you rising at what pace? is this happening? Should I put more insulin and should I not? The data from the Dexcom g six is going to help you make that decision. All of the things you're hearing in the Juicebox Podcast. And even more specifically in this diabetes pro tip series. If you'd like to put those things into practice, if you'd like to grab diabetes by the you know what, and just bring it snack and say I've had enough of this, I want to eat Chinese food, I want to have a pizza, I don't want my agency to be 12. Because of that, I don't want to spike the 400 I just want to eat. I think you can do that with the Dexcom. Now my results are mine and yours may vary. But I got a good feeling dexcom.com forward slash juice box or links in your show notes or Juicebox podcast.com. I mean, even if you don't want the Chinese food, wouldn't you just like to sleep overnight with some comfort.

If you have an omni pod, your pump is going to be completely self contained, it will adhere to your body, the insulin will be in there and all the smarts and everything and you'll use a wireless controller to tell it hey, I want you to change my bazel or put in a bullish or something like that. All other pumps have tubing and an infusion set, right. So you'll have an infusion set that'll put your cannulation tubing will run to the pump, and that pump will have its insulin in it, you'll need to keep that with you. It'll be clipped somewhere,

Jennifer Smith, CDE 41:50
right. And that's a good point to make to about the difference on the pod. The PDM does not have to be on your person for the pod to continue delivering. That's a big question that a lot of people have, well, I don't want to carry around this extra thing all the time. You don't have to once the pod has been told what to do. It does it

Scott Benner 42:09
as soon as it beeps and it recognizes the signal you're done. Actually you can walk away from if your insulin starts in like say you're putting into reverence delivering, right? As soon as it starts to walk away. You could you could run to, you could run across the state and your pdmp in your house and the insulin will keep delivering Yeah. It's also important to talk about there about pumping in general is that to bathe or swim on a tube pump, you're going to have to disconnect to more than that for most right. So even in you know more aggressive like sports, for instance, like you there's a lot of people who disconnect to go play soccer or you know, football or something like that. With Omni pod, you'll always be wearing it. I think to me, that's a huge point that made me want to do it. Because you always hear people say like, Oh, I went to the beach and I got high, I get high at the beach. And I always think back to someone who was on the show. I think it was a just a few episodes ago, where he said if you put a pencil in your back pocket, and then rob a bank, pencils don't cause bank robbery. And, and so the batch doesn't make your blood sugar high, taking your insulin pump off major blood sugar high. Right, right, like that kind of an idea. So just understand that there's different ways to manage with different pumps, I'm not telling you which pump they get.

Jennifer Smith, CDE 43:30
And that's a lifestyle look, right. And that's the biggest thing when I work with people. They're always like, what what do you think is the best? There isn't a best, there's the best for me, there's the best for you, you need to take a look at you know the pros and the cons of all of the pumps. What are the what's the pump that has the most Pros for your life, to navigate your lifestyle your needs, you know, an athlete, I've got a lot of athletes who really prefer Omni pod. Because of the tubeless piece I've worked with a lot of triathletes, who really they need I mean from going from a swim into a bike into a run, they need something that's a seamless management, then they're not having to clip in and pop in and reload and you know everything. So there? I think it takes a lot of examination of your lifestyle. Yeah,

Scott Benner 44:17
no, absolutely. There's no, I would I would jokingly say that, you know, I'm sure you think that I think you should get an omni pod. And probably if you ask me my personal opinion, I would say yes, right, not just because they advertise on the show, but because artists use one for 11 years. And it has been nothing but absolutely fantastic for us. But I completely agree with Jenna, you should decide what works best for you. You really have to do that. Not everyone's going to see the same pros and cons as everyone else.

Jennifer Smith, CDE 44:47
And all of the pumps despite delivery and mechanism of driving insulin. They all do have some features that are different and may apply better to your lifestyle than another They're brand. Absolutely.

Scott Benner 45:01
So. So again, figure it out for yourself, do your due diligence. I think the greatest thing about the Omni pod might be is that they offer a demo, they'll send you one to your house and let you try it like that, where it the other companies are at a loss, they can't really do that, because

Jennifer Smith, CDE 45:16
of the problems is set up very big and extensive.

Let me just send you Oh, and I'll send it back. Yeah,

Scott Benner 45:22
please, please give it back. And a couple of other ideas. And he's it right, so what I was getting to whether you're using it on the pod, or you're using another one, there's going to be some adhesive of some sort, you know, a simple preparation, like we talked about back in the MDI episode, I think I don't over prep, skin, right? clean skin.

Jennifer Smith, CDE 45:44
Right, without lotion or anything on it, you're good to put it on. You could see.

Scott Benner 45:51
You know, if you have soreness with a pump, right, it shouldn't hurt. No, right. So it should not. So be careful. Like, if you start if you have soreness that you know, I mean, after it first goes on, obviously, you know, it's not fun to have a hole poked in you. And that's going to be done by any one of these pumps. But an hour later, whatever it is, if it's hurts, or it's hard to bend your arm, sometimes the candle can hit a nerve,

Unknown Speaker 46:14
or a muscle muscle like looking up again. All of

Scott Benner 46:18
these companies will if you call them up and say, Look, I had to put it in an infusion set, and it hurts so bad. I took it out. Can you send me another one? Generally speaking, they're their customer service is good, they will?

Jennifer Smith, CDE 46:30
Correct. And that's really important because it can affect absorption at the site. If you've got a site that isn't it that's hurt, or, you know, maybe getting infected or for some reason there's irritation under the site. If that site is bothering you, there, that's not good. Remove it, pop in a new one do something.

Scott Benner 46:47
Yeah, don't sit in pain. Yeah. And that I think that's important. tubing is something I don't completely understand I how much tubing Do I need is it just as much to get me to where I want to store my pump?

Jennifer Smith, CDE 47:04
Correct in that depends, you know, tubing comes in many, many different lengths for the tube pumps being of which there are only two on the on the market, either tandem or Medtronic are the tube pumps that are available now, at least here in the States. So the tubing length depends on exactly where you're going to move that pump to and pop it in. If it's in a pocket, you may need short tubing 18 inches, if you're going as some some of the guys that work with, you know where the shirt stays around their lower leg to keep their shirts tucked in, well, they end up just clipping their pump down their leg, and then they can easily lift up their pant leg to Bolus during the day. So if that's the case, you probably want 40 plus inches, tubing. how tall you are, you know, if you're Shaq, you probably need like

inches but yes,

Scott Benner 47:57
and and the two pumps also you when you go to put them on, they have to be primed, which means that you have to fill all of that tubing with insulin. Before you can put it on the pod self Prime's. So you when you there's no tubing, there's no tubing, there's a tiny little candle that that obviously goes under your skin stays there. Yep. So again, there you go. There's pros and cons with all of them. You know, I hear people say that so on the pod has a failsafe, right? If it gets around too much electrostatic electricity, and it and it affects the internals of it, it will shut down and ask you to do to change it. Yep. I've had it happen in 11 years, six or seven times, you know, it's happened. And people go, Well, that doesn't happen with a tube pump. And I'll say Well, yeah, and my daughter is also never walked past the drawer in the kitchen and gotten her tubing caught on and yanked out her infusion set. Oh, that's the tube pump version of that, to me, like they all have something if you're looking for something right? If you're looking for perfection. They don't ask a machine to do anything on it. Absolutely.

Jennifer Smith, CDE 49:03
And I think you know, one even that might be going towards the the tube pump potential need would be if, for some reason, the angle of the kanuma is a concern or an issue for you. That is one I would say potential drawback of Omnipod is that there's only one canula it comes on every pod it's exactly the same canula and it goes in exactly the same angle for every single person, which may not again, your diabetes will vary because your body physiology may be very different. So you may need to choose the pump. Despite not wanting tubing, you may need to choose a pump. That's too because you need a different type of canula or what's called infusion set. You may need something to go in at an 80 degree angle versus an angled you know, you may need a steel canula versus a plastic kanila for various body reasons. So there are a lot of considerations

Scott Benner 50:00
Yeah, absolutely. But don't take, don't you keep this in mind, no matter what pump you're thinking about. I know this is gonna sound a little dirty. But it's, it ends up being true. Companies have salespeople, salespeople influence doctors, doctors get stuck prescribing things right over and over, you walk into an office and say I want it on the pot. And the guy goes, No, no, you want one of these? Trust me, you don't need to trust him. You know, you can say that you appreciate your input. But I'd really like to try the on the pot or vice versa, I don't want it on the pot, I really would like to try that. You can you can, you can speak up for yourself, please, please do that. Absolutely do that. So at the very end of this, I want to talk about about something that can't, it doesn't happen with injections that could happen with a pump, right. So as long as you inject your insulin with your injections, you remember to put in your Atlantis, you'll never marry your trustee. But whatever it is, and you you know, remember to put in your insulin for your food or your high blood sugars, you're watching the needle go in your arm, you're pushing the button, you pull it away, you know the insulins in there. With any insulin pump, the possibility could exist that your canula could get bent, that your tubing could get kinked that the pump could, I don't know, the batteries could die like like, you know, on the pod doesn't have batteries. And there's the but the other ones, there's mechanical, you leave the house and totally forget that your reservoir only had five units. And for the rest of the day, you actually needed 20 units. And now you have no influence area and you're in trouble. Right? Right. So these are things that could happen when you try I we have a radius in my mind, if I'm more than 30 minutes away from my house for any extended period of time. I bring insulin and another pump with us. The other day, we drove an hour and a half to something stayed there all day had all this extra diabetes supplies with us didn't need one of them. You know, most of the time you don't need it. But when it happens, it happens. Now, in 11 years, I'm happy to tell this story in 11 years, we've had one insulin delivery problem with Omni pod. And it wasn't the pump. It was us. We changed the pump by sight. And it you know, it was at a pool. Right? So we put it on and I she got back in the water. And I think the adhesive didn't have time to adhere and it loosened up a little bit and it pulled her canyelles out. Oh yeah, of course of a day right along July day of swimming. We got home her blood sugar was still fine now. Was it still fine because the candle was still in it hadn't worked its way out yet because she was so active during the day. She didn't need as much as I don't know. But what I can tell you is, is that overnight Arden's blood sugar started to skyrocket. And I kept bolusing. And it took me a while to figure out that my boluses weren't doing anything. That's not going to happen to you injecting. Right? So is it is it I actually saw a person say the other day, I'm scared to get a pump because of that. And I think if that's why you're scared, I think you're worrying about things you don't need to worry about. But you do need to be aware of them. Correct, right? Your tube tube kinks, something happens. You're not getting insulin delivery, you're also don't have any slow acting insulin. And so when you lose your pump, you lose your slow and your fast acting you can go from everything's right on to DK a. Pretty fast, quick.

Jennifer Smith, CDE 53:30
Exactly, absolutely. And that's, it's a really good piece, you know, to discuss because it's one of the primary things when I work with starting somebody on a pump that we discuss, right in the pump training, is the risk for decay or the risk for a pump malfunction. And how do you how do you navigate that without having such tremendously high blood sugars that then take forever to bring down because you're at such a deficit of insulin right? I mean, our recommendations really are with a pump, an odd high blood sugar or now with the use of a CGM blood sugars that are like you said, just all of a sudden skyrocketing, and there should be no reason for that skyrocket like you didn't go eat the whole Dairy Queen cake and just not bolus for it right. There is something wrong, you bolus from the pump. If that initial bolus doesn't start to make a dent in that glucose within the next 30 to 60 minutes, you change everything out you change the site, the tubing, the reservoir, the pod, whatever you might even change the insulin you know especially if it's been a D at the beach and your insulin hasn't been kept change the insulin out really important I

Scott Benner 54:41
bail on a pump site. As soon as as soon as I know too. I will sometimes if I if I get a stuck number, but it's not too high. Sometimes I'll inject a little bit. And if you inject instead you go oh my god, it started moving right away. Maybe I'm gonna get off this pump site like a little banner. And that's, you know, to just go over a couple of like ideas, you can't keep reusing the same site over and over again, they eventually become less effective. For reasons we talked about in other episodes, you have to understand that when you when you put in an insulin pump, you've you've needle has poked a hole in you, and left behind a piece of plastic in most cases, right? This plastic is a foreign body. You're right, it's an irritant. I remember discussing with Aaron Kowalski from the jdrf, one time that he thinks one of the most ignored technologies for people with diabetes that we don't spend enough r&d time on is cannulated materials, and how to make them less irritating to the body. Because when your body thinks it's injured, it sends white blood cells to the place it believes there's an injury. And I don't know anything technical, but in my mind's eye, in my mind's eye that draws cartoons of what I think the world looks like, and how I understand things. There's little white blood cells, sort of like the beginning of Jurassic Park, when they show that cartoon to explain that I know DNA, in my mind, I see little white blood cells coming and attaching themselves around that Canyon and making my insulin not flow correctly. I know none of that's probably technically correct. But I do know that when a when a place gets irritated like that, that insulin becomes less effective. And there are times you have to bail on a site sooner than you want to.

Jennifer Smith, CDE 56:26
It could be and it's also a good just around site change itself to be very aware that the potential for that new site to be less absorptive, from really what you're talking about, there is inflammation. Anytime you introduce something underneath the skin, you ask your body to become irritated. And inflammation is what follows. So an absorption at that site is significantly decreased. Everybody's a little bit different. Some people it's for about an hour, some people it could last as long as four, six hours, that inflammatory response. It's also a guess, for those who are using a continuous glucose monitor, you know, that two hour thinking window? Yeah, a big reason for that to our sinking window. Besides that sensor needing to get wet, you've put something to sit underneath your skin, your body's got to get used to that and you don't want glucose values coming in, from a site that's probably injured. Right? So same with a pump, you really have to pay attention. What do your site changes look like? How does your glucose level change around site change time? And is this normal? Is this a normal flux in glucose? Or is my gosh, my blood sugar's never 300 after I change the site, right there in lies the difference of change it out or figure out how to navigate the site change, so you don't have a high blood sugar. And I think it's incredibly important to know that while this may sound scary, that you'll figure it out very quickly.

Scott Benner 57:54
It's not something that's going to dog you for your entire existence. There's little is the word peccadilloes, there's small things about everything that you have to you have to figure out along the way. And the only way just like we talked about within, the only way to figure it out is to do it. Let it go the way you didn't expect, you know, suss out what happened and and fix it next time. I think

Jennifer Smith, CDE 58:16
just the fact in you know, this episode, especially talking about these little pieces. It's really, really important because these are pieces that are often not talked about from an endo education standpoint. They're not they're missed. They're things that you figured out along the way. And you've talked to other people, and you're like, Ah, I'm not the crazy, man. This is what's happening. Right? Me, me, too. I mean, I, I could have sat and asked my endo about it. But there's things that in interjecting and working with other people and my own self experience. I'm like, I'm not crazy. This is what happens. And I'm not the only one great

Scott Benner 58:57
example, that when RM is younger, and we changed her pump, she'd get high. And people say, Oh, that's a thing. That's a pod chain tide only happens with Omni pod, and blah, blah, blah. And I'm like, you have to Bolus mark with Bolus with the old pod before you change the new pod because the new pod won't work and everything. None of that was the truth. You want to know the truth. Arden was incredibly nervous to get her insulin pump change when she was little, and the adrenaline would hit her and shoot her blood sugar up. And one day, Arden stop being nervous about having your insulin pump changed. And that all stopped. There was no match. So people had had imagined this entire story around this and I started buying into it at first I was like, oh, obviously the pump doesn't work right away and and all this and by the way, it doesn't it that's not an unnecessarily incorrect statement. There like you just said new inflammation. There's an injury, you do sometimes need more insulin. upfront and I don't disagree with that. But the leap she got wasn't the pump changing. adrenaline's adrenaline. And I still, like we talked about earlier, a new pump. As soon as I put on a new pump, I double the bazel for an hour, like, right, just to get it going. But, but I started thinking down that it's again, this cause and effect, it's the pencil in your pocket, right? Like, I changed the pump in her blood sugar went up, obviously, the pumps not delivering insulin anymore. Make sense? didn't end up being correct. Right? Right. So just you'll figure it out.

Jennifer Smith, CDE 1:00:32
My experience was coming from a tube pump to Omnipod. So I had experience with site change from a tube standpoint on the Omnipod. And I'm glad that I had that. Because I do experience that site change inflammation. And I had experienced it on a tube pump with the canula. And so I knew it was likely going to still happen on Omni pod. So, you know, again, your experience is going to be different from somebody else's.

Scott Benner 1:00:59
It's 100%. Right? Ah, good. Oh, did we didn't miss anything? Do we do okay? I think I like what you said at the end. I appreciate it. Because I wanted this to be a real real conversation. Not some like shiny. Oh, you'll get a pump and you'll love it. And it's gonna end by the way you will love it. It's in we won't. I don't know who you are. You know, I can tell you it's been an amazing experience for us, I believe wholeheartedly that the Omni pod is one half of the reason that we are able to keep Arden's agency where it is

Jennifer Smith, CDE 1:01:30
where it is. Absolutely. And I see the population of people that come off of a pump is small. But there are people who I've got a good friend who pumped for years and was like, man, she had a major issue with her pump. And she was like, No, I'm, I want to make sure I know I'm getting my influence. She's been on bolusing. She's gone through pregnancies with bolusing via MDI, it works for her. But again, that's her choice. And most people will stay on their pump. Listen, here's

Scott Benner 1:02:00
the here's the key, be happy, be healthy. That's all I care about. It doesn't matter to me what you do, just no differently than the way I talked about using insulin. I talk about pumps and glucose monitors the exact same way. I want you to know how it works. I want you to know what to do when you try it. And once you try it, if you don't want to do it, whatever, man, I don't care. You know, like I'm not telling you what to do. I'm here telling you, you shouldn't make decisions based off of bad information. When you have good information, make good decisions, do whatever you want. If you're enjoying the Juicebox Podcast, there's a couple of things you could do. In return, let's say you could leave a rating and a review on iTunes that helps the show be more searchable so more people can find it. You can support the sponsors and I'm talking about on the pod decks, calm dancing for diabetes, and real good foods. These are the people who bring you the podcast for free. Right, right support it. The last thing you can do is tell a friend, if something you've heard on this podcast has been valuable to you. help someone else to find it. podcasts are not intuitive to everybody, you may have to send them a link, you may have to show them how to put a podcast player on their phone. I'm not sure what that will entail. But I know one thing when you share the podcast, it grows. When it grows. The sponsors are happy. And when the sponsors are happy, the podcast continues. I hope you're enjoying the diabetes pro tip series. That's going to be it for March. Jenny and I are having a fantastic time making these. I have to tell you I think maybe we might even you know keep going after this series is over.

Did you think I was gone? I'm still here. At this point, you have to be asking yourself why am I not pushing stop? It's the Curiosity right? Like you think maybe something else is gonna happen. But I'm telling you right now nothing else is gonna happen. Could you hear me breathing? I was holding my breath right there.

Thank you for listening to the Juicebox Podcast. I'll see you next week.

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